The objectives of this study are to describe the cultural context of four ICUs and to develop and compare contemporaneous perspectives of patients, families, and health care providers and their relationship to end- of-life decision making. There is evidence of poor end-of-life communication between health care providers and patients about prognosis, resuscitation, and patient preferences, and lack of implementation of patient refusals of care. The proposed qualitative study is designed to focus intensively on problematic limiting (withholding/withdrawing) of care in four adult intensive care units (ICUs); ICUs are the site of much of this type of decision making. Problematic decisions are those where there is disagreement between providers and patients or families or within these groups. Non- problematic cases will also be studied as part of the context of such care. This is a prospective ethnographic study with embedded case studies. Data collection methods will include participant observation on the four ICUs and semi-structured interviews of providers, patients, and families to provide (a) information about each unit's culture with respect to end- of-life issues, and to provide (b) an understanding of varying participants' real time perspectives on limitation of treatment decisions, which will be used to develop multiple case studies. This approach should identify barriers to and facilitators of good decision making. With a description of such barriers and facilitators, it will be possible to design interventions to serve patients' interests and be mutually acceptable to patients, families, and health care providers.